Care Coordinator - Enhanced Care Management

ABOUT US:

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

As a private, non-profit 501(C) (3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 100,000 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.

We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.

ROLE OVERVIEW and PURPOSE:

The Care Coordinator will coordinate care for complex patients with mental illness, substance use disorders, or chronic conditions to navigate and link with community resources that address social determinants of health (SDOH). This role will provide care coordination and connection to services and social supports for ECM patients, including appointment scheduling and referral management. Additionally, this position will require travel to other Neighborhood sites as needed to attend the designated meetings as well as training for staff members.

**This is a hybrid position; on site expectations are dependent on performance. **

RESPONSIBILITIES:

• Provides ongoing monitoring of the Targeted Engagement List (TEL)
• Assigns patients to the appropriate ECM team members based on risk category and available clinical data for ECM engagement activities
• Works with a caseload of patients identified as being low risk
• Conducts periodic telephonic outreach and follow-up to low-risk ECM patients as outlined in the Shared Care Plan
• Supports other ECM team members with delegated tasks
• Assists in the coordination of appointments and referrals for physical and behavioral health appointments
• Collaborates on patient care issues with other ECM team members, participating in weekly systematic case reviews and ad hoc case reviews, and consults with ECM team RN and/or the Behavioral Health care team RN before taking any action that is clinical in nature
• Connects ECM patients to other social services and supports they may need
• Uses relationship-based strategies to engage patients in care as well as motivational interviewing
• Assists with arrangements such as transportation, directions, and completion of durable medical equipment requests
• Coordinates with ECM patient in the most easily accessible setting, within IEHP guidelines, such as patient home, provider/regional office, or other settings
• Contributes to the success of the organization by participating in quality improvement activities
• Documents in ECW for all care coordination and other services or teaching provided in a timely manner, as needed
• Prioritizes activities according to intensity, need, and required follow-up
• Provides accurate and timely reports to supervisor and site staff, as required

EDUCATION/EXPERIENCE:

• High school diploma or equivalent required
• Two years of healthcare, behavioral health, or social services industry experience required
• Active CA driver’s license and proof of car insurance required
• Medical Assistant or Phlebotomy certificate preferred
• Bilingual (English/Spanish) preferred

ADDITIONAL QUALIFICATIONS (Knowledge, Skills and Abilities):

• Excellent verbal and written communication skills, including superior composition, typing, and proofreading skills
• Ability to interact effectively with clinic personnel, patients, and community-based organizations
• Knowledgeable about evidenced based communication such as motivational interviewing, or similar empathy-based communication strategies (emotional intelligence)
• Knowledge about and experience with providing sensitivity to patients with mental health conditions and addictive disorders
• Ability to resolve problems/conflicts
• Ability to navigate computer applications, including Microsoft applications
• Ability to sufficiently engage members and providers both on the phone and in person
• Ability to successfully manage multiple tasks simultaneously
• Excellent planning and organizational ability
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 25 lbs/weight
• Ability to stand for long periods of time

COMPLIANCE (Safety & HIPAA)